United Behavioral Health/US Behavioral Health ... - Ubhonline.com

IMPORTANT TAX DOCUMENT
SUBSTITUTE FORM W-9
Request for Taxpayer Identification Number
As part of the contracting process, we are requesting that you complete this Substitute Form W-9 for each TIN.
We are required by law to obtain this information from you when making a reportable payment to you. If you do
not provide us with this information, your payments may be subject to 31% federal income tax backup
withholding. Also, if you do not provide us with this information, you may be subject to a $50 penalty imposed
by the Internal Revenue Service under Section 6723 of the Internal Revenue Code.
This information must be consistent with the data provided on Page 2 of the application (Office
information).
1. Taxpayer Name
(To whom the check is payable)
Doing Business as:
(A division name if a corporation or the
name of the business if a sole proprietor)
2. Taxpayer Address
DBA
(A legal entity name if a corporation or partnership)
3. Taxpayer Identification Number
a. Corporation
b. Partnership
c. Sole Proprietorship
d. Tax Exempt Entity
e. Other - Please Explain
(List employer identification number)
(List employer identification number)
(List social security number or employer identification number)
(List employer identification number)
4. Effective Date of Taxpayer Name
& TIN
5. Form Completed By
Print name)
6. Signature
(Signature)
7. Today's Date
8. Daytime Phone Number ( )
PLEASE NOTE: INFORMATION REPORTED ON LINES 1-3 MUST BE CONSISTENT WITH DATA ON FILE
WITH THE IRS AND SOCIAL SECURITY ADMINISTRATION.
@UBH/USBHPC/LEI 6/2004 Page 10